Perfusion is Not Measurably Decreased in Idiopathic Clubfoot

BACKGROUND

Vascular aberration has been accepted as a potential etiology of clubfoot, and abnormal vasculature has been observed in as high as 85% of children with severe clubfoot. The perfusion index (PI) corresponds to the ratio of pulsatile to nonpulsatile blood flow at a monitoring site and can be used to quantify perfusion of the extremities. The purpose of this study was to use PI to compare the perfusion of clubfeet to controls in order to further assess the role of abnormal vasculature in clubfoot.

METHODS

A Masimo Radical 7 Pulse Oximeter (Masimo Corporation, Irvine, California) was used to measure the PI and oxygen saturation (SpO2) of the feet of children 5 years of age and younger with and without clubfoot. The sensor was placed on the great toe. Patients with clubfoot undergoing non-operative treatment and control patients undergoing treatment in a clinic for orthopedic concerns not involving the foot and with no known vascular issues were assessed. The PI and SpO2 for the following three groups were compared: 1. affected feet of patients with bilateral or unilateral clubfoot, 2. unaffected feet of patients with unilateral clubfoot, and 3. control feet.

RESULTS

One hundred and twenty-eight patients were enrolled, 64 with clubfoot (31 bilateral and 33 unilateral) and 64 controls. No significant differences in PI or SpO2 were found between: 64 clubfeet and 64 feet of controls (PI of 2.9 vs. 2.9, p = 0.984; SpO2 of 97.1 vs. 98.1, p = 0.192); unaffected feet of 30 patients with unilateral clubfoot and 64 controls (PI of 3.0 vs.2.9, p = 0.907; SpO2 of 96.9 vs. 98.1, p = 0.224); and affected and unaffected feet of 30 patients with unilateral clubfoot (PI of 3.3 vs.3.0, p = 0.500; SpO2 of 97.4 vs. 96.9, p = 0.527).

CONCLUSIONS

No difference was observed in the PI or SpO2 when comparing affected clubfoot limbs with unaffected limbs, suggesting that vascular anomalies cannot fully explain the development of clubfoot.

Treatment of Idiopathic Clubfoot in the Ponseti Era and Beyond

The initial treatment of idiopathic clubfoot was mostly surgical for the 1980s/1990s. In the latter half of the 1990s, there was a surge of interest in the Ponseti method of casting after the publication of Dr. Ponseti's 30-year results. Many authors have since shown correction rates in the high 90th percentile, rendering posteromedial release surgery almost obsolete. The success of the Ponseti method has been brought internationally and extrapolated to more and more difficult cases, such as idiopathic or syndromic, primary or recurrence. This new trend will create a different subset of complications.

Calcaneocuboid arthrodesis for recurrent clubfeet: what is the outcome at 17-year follow-up?

PURPOSE

Calcaneocuboid arthrodesis was used during revision clubfoot surgery in order to maintain midfoot correction. The purposes of this study were to determine: (1) functional level at 17-year follow-up compared to 5-year follow-up; (2) patients' current functional level, satisfaction, and pain; and (3) current arthropometric measurements.

METHODS

Twenty patients (27 clubfeet) with clubfoot relapse underwent revision soft tissue release and calcaneocuboid fusion between 1991 and 1994. They were previously evaluated at a mean follow-up of 5.5 years. Ten out of 20 patients (13 clubfeet), mean age of 24 years, were reevaluated at mean follow-up of 17.5 years. The Hospital for Joint Diseases Functional Rating System (HJD FRS) for clubfoot surgery, Outcome Evaluation in Clubfoot developed by the International Clubfoot Study Group, the Clubfoot Disease-Specific Instrument, American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire, Laaveg and Ponseti's functional rating system for clubfoot and pain scale were completed by patient and/or surgeon to assess function, patient satisfaction and pain. Foot and ankle radiographs and anthropometric measurements were reviewed. For HJD FRS, scores from original follow-up were compared to current ones.

RESULTS

The HJD FRS score of all feet was 65.9, demonstrating a significant decline from the original mean score of 77.8 (p = 0.03). Excellent/good HJD FRS scores went from 85 to 38 %. Mean AAOS Foot Ankle Outcomes Questionnaire standardized core and shoe comfort scores were 84.6 and 84.5, respectively. Average foot pain was 1.8 on a scale of 1-10. Patients were very/somewhat satisfied with status of foot in 76 % of feet and appearance of foot in 46 % of feet, based on Clubfoot Disease-Specific Instrument questions.

CONCLUSIONS

Revision clubfoot surgery with calcaneocuboid fusion in patients 5-8 years of age showed an expected decline in functional outcome measures over a 17-year follow-up period. It still produced comparable results to other studies for a similar population of difficult, revision cases, and should have a place in current surgical treatment techniques.

Idiopathic clubfoot treated with the Ponseti method: factors associated with patient follow-up

BACKGROUND

Follow-up after treatment with the Ponseti method is important because of the known association be- tween lack of brace wear and recurrence. This study was designed to ascertain factors associated with patients who did not return for the recommended follow-up versus those who did.

METHODS

Between January 1, 2000, and December 31, 2009, 222 patients were treated for idiopathic clubfoot at the New York Ponseti Clubfoot Center at NYU Hospital for Joint Diseases, of which 93 patients (143 feet) were potentially available for follow-up (i.e., ≤ 7 years of age, had not moved, or transferred care to another institution). Attempts were made to contact all patients' parents or guardians by telephone to respond to a survey, which included questions from the Disease Specific Instrument and the Oxford Ankle Foot Questionnaire. Forty-two of the 93 patients (45%) responded. The responder group, those who answered the survey, was compared to the group of non-responders. The responder group was further divided into a returning group (35 out of 42, 83%) and a lost to follow-up group (17%, not followed-up in over a year). A chart review was performed for demographics, Dimeglio/Bensahel and Catterall/Pirani scores, and treatment.

RESULTS

When comparing the responder and non- responder groups, the responder group had significantly lower (p < 0.05) Catterall/Pirani scores at initial visit than the non-responder group (5.0 versus 5.5), but otherwise these two groups were similar. Among the responders, 91% or more were very satisfied/satisfied with status and appearance of foot in both lost to follow-up and returning groups. The lost to follow-up group was significantly (p < 0.05) older at the time of the survey (5 years versus 3.7 years), required significantly fewer casts (4.4 versus 5.5), had significantly lower Dimeglio/Bensahel scores at time of the start of foot adbuction orthoses (FAO) (0.0 versus 2.0), and trended toward greater footwear limitations (p = 0.051) compared with the returning group.

CONCLUSIONS

Number of casts, severity scores at the start of FAO, and footwear limitations are possible factors to differentiate between lost to follow-up and returning patients. This information may help other clubfoot centers provide vigilant outreach and therefore decrease recurrence rate.

Correction of clubfoot deformity associated with Weber type I tibial hemimelia using the Ponseti method

The clubfoot deformity associated with Weber type I tibial hemimelia, a rare congenital disorder, is rigid and difficult to correct. Surgeons have utilized a variety of treatment methods. Since the 1960s, some adopted the Syme amputation to produce a weightbearing lower limb. Others began to explore alternatives such as the Ilizarov technique, ankle reconstruction, and casting, which salvage the foot but have produced mixed results. The current investigators suggest that the Ponseti method, a minimally invasive technique, can produce a functional weightbearing foot. Two cases were treated with the Ponseti method, including a percutaneous Achilles tenotomy and post-cast bracing. After a minimum of 2-years follow-up, both are ambulatory.

Correction of arthrogrypotic clubfoot with a modified Ponseti technique

Surgical releases for arthrogrypotic clubfeet have high recurrence rates, require further surgery, and result in short, painful feet. We asked whether a modified Ponseti technique could achieve plantigrade, braceable feet. Ten patients (mean age, 16.2 months; range, 3-40 months), with 19 arthrogrypotic clubfeet, underwent an initial percutaneous Achilles tenotomy to unlock the calcaneus from the posterior tibia followed by weekly Ponseti-style casts. A second percutaneous Achilles tenotomy was performed in 53%. Mean number of casts was 7.7 (range, 4-12). From pretreatment to completion of initial series of casts, mean scores of Dimeglio et al. improved from 16 to 5 (ranges, 12-18 and 2-9, respectively), Catterall scores (as modified by Pirani and colleagues) from 4.8 to 0.9 (ranges, 1.5-6.0 and 0.0-2.0), and maximum passive dorsiflexion from -45 degrees (range, -75 degrees to -20 degrees ) to 10 degrees (range, 0 degrees to 40 degrees ). Ankle-foot orthoses maintained correction. At the minimum followup of 13 months (mean, 38.5 months; range, 13-70 months), the mean maximum dorsiflexion was 5 degrees (range, -20 degrees to 20 degrees ), two patients had posterior releases and no patient's ambulatory ability was compromised by foot shape. Arthrogrypotic clubfeet can be corrected without extensive surgery during infancy or early childhood. Limited surgery may be required as the children age.

Treatment of idiopathic clubfoot using the Ponseti method: minimum 2-year follow-up

One hundred and thirty-seven idiopathic clubfeet were treated by the Ponseti technique and followed for at least 2 years. Nine feet (7%) were not corrected with initial casting and required early surgery. Recurrence after correction was related to compliance with bracing. At latest follow-up, two-thirds of those noncompliant with brace had recurrences with one-third of these recurrences requiring more extensive surgery than Achilles tenotomy and anterior tibial tendon transfer while only 14% of those compliant with brace had recurrences with none requiring more than Achilles tenotomy and anterior tibial tendon transfer. Early failures and recurrences constituted about 20% of our 137 feet by 2 years of follow-up. When the Ponseti method was fully followed, including initial casting, compliance with brace and treatment of recurrences by recasting, Achilles tenotomy and/or anterior tibial tendon transfer, our success rate was 93%.

Accuracy of correction of tibia vara: acute versus gradual correction

The purpose was to assess the accuracy of deformity correction achieved in patients with tibia vara using acute intraoperative correction compared with gradual postoperative correction. Acute correction (AC) group consisted of 14 patients (14 tibiae) with a mean age of 11.4 years and whose tibia vara was corrected acutely and held using an EBI external fixator. Gradual correction (GC) group consisted of 18 patients (18 tibiae) with a mean age of 10.2 years and whose tibia vara was corrected gradually using 6-axis deformity analysis and Taylor Spatial Frame. Deformity measurements were compared preoperatively, postoperatively, and at latest follow-up. At latest follow-up, medial proximal tibial angle deviation from normal was similar for the 2 groups; posterior proximal tibial angle was significantly greater in the AC group (5.6 degrees) than in the GC group (1.9 degrees). Mechanical axis deviation was significantly greater in the AC group (17.1 mm) than in the GC group (3.1 mm). Postoperatively, frequency of accurate translation corrections (achieved translation within 5 mm of preoperative required translation) was significantly greater in the GC group (18/18) than in the AC group (7/14). Frequency of accurate angulation corrections (medial proximal tibial angle within 3 degrees of normal and posterior proximal tibial angle within 5 degrees of normal) was significantly greater in the GC group (17/18) than in the AC group (7/14). For both groups, all tibiae with preoperative internal rotation deformity had accurate rotation correction. Correction of preoperative limb-length inequality was achieved in 5 of the 7 patients in the AC group and 11 of the 11 patients in the GC group. Gradual deformity correction is a more accurate treatment method of tibia vara than acute correction.

Interobserver and intraobserver reliability of radiographic evidence of bone healing at osteotomy sites

Plain radiographs are commonly used to evaluate the degree of bone healing after an osteotomy and the application of an external fixator. The purpose of the study was to assess intraobserver and interobserver reliability in determining bone healing, defined as bridging callus across three of four cortices, of osteotomy sites on radiographs. Substantial intraobserver reliability and a high intraobserver percentage agreement were found. Interobserver reliability was moderate and interobserver percentage agreement was less than half for agreement between all involved orthopaedic surgeons. The lower reliability across surgeons suggests that the determination of the extent of the bone healing is subjective.

Use of the foot abduction orthosis following Ponseti casts: is it essential?

The purpose of this study was to evaluate the need for the use of a foot abduction orthosis (FAO) in the treatment of idiopathic clubfeet using the Ponseti technique. Forty-four idiopathic clubfeet were treated with casting using the Ponseti method followed by FAO application. Compliance was defined as full-time FAO use for 3 months and part-time use subsequently. Noncompliance was failure to fulfill the criteria during the first 9 months after casting. Feet were rated according to the Dimeglio and Pirani scoring systems at initial presentation, at the time of FAO application, and at 6 to 9 months of follow-up. At the time of application, no significant differences in scores were found between the groups. At follow-up, the compliant group's scores were significantly (P < 0.01) better than those of the noncompliant group. From the time of application to follow-up, for the compliant group, the Dimeglio scores improved significantly (P = 0.005). For the noncompliant group, the Dimeglio scores deteriorated significantly (P = 0.001). The feet of patients compliant with FAO use remained better corrected than the feet of those patients who were not compliant. Proper use of FAO is essential for successful application of the Ponseti technique.

Reminder: radiopacities from metal-containing substances

A 17-month-old boy with a toed-out left lower extremity was presented for evaluation. Before coming to the doctor, the mother had applied a zinc oxide lotion to treat a simple diaper rash in the groin. The radiologist did not remove the boy's diaper for the radiographic examination and so did not notice the lotion. The first radiograph showed what looked like multiple soft-tissue calcifications in the groin, but the radiopacities had been produced by the zinc oxide. This case serves as a reminder to be aware that metal-containing substances both on and in the body can produce radiopacities.

Predicting the need for tenotomy in the Ponseti method for correction of clubfeet

The purpose of this study was to determine how to predict the need for tenotomy at the initiation of the Ponseti treatment. Fifty clubfeet (35 patients) were prospectively rated according to Pirani and Dimeglio scoring systems. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required significantly more casts (P = 0.005). Of 27 feet with initial Pirani scores > or = 5.0, 85.2% required a tenotomy and 14.8% did not; 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and did not have a tenotomy. Children with clubfeet who have an initial score of > or = 5.0 by the Pirani system or are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy.

Surgical technique for an 'almost' percutaneous triple pelvic osteotomy for femoral head coverage in children 6-14 years of age

A relatively simple triple pelvic osteotomy using two cosmetically small skin incisions can provide excellent coverage of the femoral head. An adductor approach and a bikini approach are used to do the osteotomy. The 'almost' percutaneous pelvic osteotomy successfully increases femoral head coverage in a concentric hip joint. The VCA angle of Lequesne and the center-edge angle of Wiberg both show significant improvement in the coverage of the femoral head. Three-dimensional computed tomography scanograms may provide a more graphic representation before and after surgery. Preoperatively, this is especially useful in evaluating posterior acetabular coverage of the femoral head. The almost percutaneous pelvic osteotomy is another possible triple pelvic osteotomy for procedures for hip dysplasia. It has a relatively low learning curve in comparison with other triple pelvic osteotomies for hip dysplasia in children aged 6-14 years. With careful patient selection, femoral head coverage can be improved with small incisions that are cosmetically acceptable.

Correction of tibia vara with six-axis deformity analysis and the Taylor Spatial Frame

Operative correction for infantile and adolescent tibia vara has been described using both external and internal fixation. Gradual correction using a circular fixator offers the advantage of accurate coronal, sagittal, and axial plane correction without significant soft tissue dissection. This study evaluated the use of six-axis deformity analysis and the Taylor Spatial Frame (TSF) for the correction of tibia vara. Nineteen patients (22 tibias), 6 with infantile and 13 with adolescent tibia vara, underwent correction with TSF. On the basis of mechanical axis correction, 21 of 22 tibias were corrected within 3 degrees of normal. Using Schoenecker's criteria, all patients achieved good results (no pain, <5 degrees difference in tibial-femoral angle from the normal side). Complications included one intractable pin-site infection, two superficial pin-site infections, and one delayed union. Six-axis deformity analysis and TSF provide accurate and safe correction of infantile and adolescent tibia vara.

A method for the early evaluation of the Ponseti (Iowa) technique for the treatment of idiopathic clubfoot

The Ponseti casting technique is reported to have a high success rate in the treatment of idiopathic clubfoot. Non-operative treatment of clubfoot provides a lower complication rate, less pain, and higher function as the patient ages than operative treatment. To demonstrate serial post-treatment change in clubfeet over time, three clubfoot rating systems were utilized in the current study. Patients compliant with the Ponseti technique and treated before the age of 7 months, had a 92% success rate at an early follow-up after casting was completed. It is not the purpose of this article to analyze the long-term clubfoot treatment result but to establish tools which can be used to judge initial success with the Ponseti technique. Complications are few and minor, limited to equipment used and cast technique.

Congenital clubfoot

Although the etiology of congenital clubfoot remains unknown, reproducible pretreatment grading now seems possible. However, the lack of an agreed-on and reproducible posttreatment evaluation system still hinders outcome studies of the treatment of clubfoot. The literature from about 1970 to 1990 contains enthusiastic reports on the correction of congenital clubfoot through extensive surgical release procedures. Over time, we have come to recognize the complications of such surgery, including recurrence, overcorrection, stiffness, and pain (WJ Shaughnessy, MD, P Dechet, MD, HB Kitaoka, MD, Vancouver, BC, Canada, unpublished data, 2000). Perhaps because of these findings, there is a renewed interest in nonsurgical techniques for the correction of congenital clubfoot. Recent studies have documented the effectiveness of the two leading techniques involving serial manipulation and cast treatment. The Ponseti technique appears to be effective and requires only a reasonable amount of time out of the lives of the patient and his or her parents. The technique frequently includes some minimally invasive surgery. The Kite and Lovell technique requires minimally invasive surgery less often but is more time consuming. French investigators and others have introduced new ideas that may reduce the need to immobilize the foot. The French approach requires fairly extensive physical therapy and demands substantial parental time and attention. It is not yet clear that the French technique is more successful in obviating the need for surgery than is expertly applied serial manipulation and cast immobilization. It also has not been proved that the long-term results of the French technique are better than those of serial manipulation and cast immobilization. It is probably that unless the French technique is found to substantially decrease the need for surgery, it will prove to be less cost effective than serial manipulation and cast immobilization. It is likely that a small number of clubfeet will require surgery even after expertly applied nonsurgical treatment. However, it is hoped that such surgery will be less extensive than procedures commonly performed in the recent past.

Percutaneous fixation in clubfoot surgery: a radiographic and gait study

Twenty patients with Type II clubfeet were evaluated an average of 3.1 years after complete surgical soft tissue release. A pinned group had fixation of the talonavicular and calcaneocuboid joints and a non-pinned group had no fixation. The control group consisted of 10 children without foot ailments. Radiographic measurements of talocalcaneal and talus-first metatarsal angles and frequencies of dorsal and medial navicular subluxation were not different for the two treatment groups. Foot progression angle was not significantly different for the two treatment groups, but was significantly different between all clubfoot patients (3.6 degrees of in-toeing) and the control group (5.0 degrees of out-toeing). Tourniquet time was significantly greater for the pinned than for the non-pinned group, but the duration of surgery was similar. Similar radiographic and gait measurement findings suggest that clubfoot surgery with and without percutaneous fixation have comparable outcomes.

Hip arthrodesis in adolescents using external fixation

Between 1994 and 1998, seven adolescents underwent hip arthrodesis with the use of an external fixator. Mean time of follow-up was 24.0 months after surgery. The duration of fixation and time to fusion were 6.6 months (range, 5-9.5 months) and 8.0 months (range, 5.2-15 months), respectively. At most recent follow-up, there was a significant improvement in the mean modified Harris hip score, in which the maximum score is 91 points after omitting 9 points for hip range of motion and deformity, from 25.7 before surgery to 66.7 after surgery (p < 0.01). The advantages of this procedure include (i) the ease and accuracy of obtaining the proper position for fusion, (ii) the ability to lengthen the affected leg at the same time, (iii) the diminished likelihood of compromising future hip operations, and (iv) the ability to ambulate and bear weight throughout the treatment course. We recommend this method of hip arthrodesis with external fixation for patients with intractable hip pain necessitating this procedure.

Melorheostosis: case report with radiologic-pathologic correlation

Melorheostosis is an unusual mesenchymal dysplasia, which commonly presents on radiographs as longitudinal bars of hyperostosis in osseous structures. We present a case of melorheostosis in the lower extremity of a 20-year-old woman for which detailed radiologic- pathologic correlation was achieved due to amputation of the involved limb.

Congenital pseudoarthrosis of the tibia

Congenital pseudoarthrosis of the tibia remains one of the most difficult conditions to treat in orthopedic surgery. Seven cases were treated in our hospital by different methods. Three out of seven patients were healed, two of these refractured. At follow-up, the success rate was 14% (one out of seven cases). It is our recommendation that early primary amputation with an appropriate prosthesis should be considered, and that the final evaluation should not be based on obtaining bone union, but on the level of function of the lower extremity.

Results of complete soft tissue clubfoot release combined with calcaneocuboid fusion in the 4-year to 8-year age group following failed clubfoot release

A subset of postoperative recurrent clubfeet was isolated in a group of patients 4 to 8 years old. Twenty-seven consecutive patients who underwent redo surgery consisting of complete soft tissue clubfoot release combined with a calcaneocuboid fusion were reviewed for this study. Twenty-six feet of 27 feet in 20 patients had a long-term good result, suggesting that this procedure is the one of choice for this age group.

Hip dislocation caused by infantile myofibromatosis

An unusual case of newborn unilateral dislocated hip is presented. The condition was refractory to conservative treatment. The cause was found during surgery at the age of 1 month: the adductors were replaced by myofibromatosis. The tumor was excised and at follow-up a normal hip was noted.

Chronic fracture-separation of the radial head in a child

A rare case of a complete fracture-separation of the proximal radial epiphysis is described in a pediatric patient. A further complicating factor is the delay in diagnosis that may worsen prognosis. An emphasis on early detection by physical examination and imaging studies, as well as consideration of treatment options, are presented.

Femoral varus derotational osteotomy in cerebral palsy

The records concerning 64 hips in 36 cerebral palsy patients treated with varus derotational osteotomy (VDO) alone (2 hips), VDO with muscle releases (adductors, iliopsoas, hamstrings; 46 hips), and VDO, soft-tissue release, and innominate bone osteotomy (16 hips) were reviewed. There were 23 quadriplegic and 13 diplegic patients. Average age at surgery was 7 years. Average follow-up period was 3.8 years. All hips that had VDO, soft-tissue release, and innominate osteotomy were stable at follow-up. Nine hips of the 44 treated with VDO and muscle release alone dislocated, and required second osteotomies.

Combined hip surgery in cerebral palsy patients

Seventeen cases of dislocated/subluxated hips in 14 cerebral palsy patients that were relocated by the combined hip procedure were reviewed. The combined hip procedure includes varus derotation osteotomy, open reduction, innominate bone osteotomy, adductor releases, and iliopsoas recession, all done at one stage. Eleven patients were spastic quadriplegic, 1 was spastic diplegic; and 2 were spastic hemiplegic. Average age at operation was 10 years. Average follow-up was 3 years. A total of 16 hips (94%) remained stable at follow-up with almost no change in center edge angle and the migration percentage, although the neck shaft angle remodeled over time. We conclude that the combined hip procedure is effective in maintaining hip reduction in cerebral palsy patients.

Minor knee trauma as a possible cause of asymmetrical proximal tibial physis closure. A case report

An unusual case is presented in which minor soft tissue injury may have caused premature asymmetrical closure of the proximal tibial physis resulting in a 30 degrees genu recurvatum that necessitated corrective osteotomy. Awareness of the possibility of a hidden physeal injury in the presence of soft tissue injury and a normal radiograph may lead to its early recognition and treatment.

Histological and radiographic determination of the age of physeal closure of the distal femur, proximal tibia, and proximal fibula of the New Zealand white rabbit

A longitudinal study was performed in a series of 124 New Zealand White rabbits to determine the radiographic versus the histologic age of closure of the growth plates of the distal femur, proximal tibia, and proximal fibula. Periodic assessment was made by standard radiographs and histological studies. Histologically, growth plates in the distal femur closed at 19-24 weeks; growth plates in the proximal tibia, at 25-32 weeks; and growth plates in the proximal fibula, at 26-32 weeks. Radiographically, evidence of closure of growth plates in the distal femur occurred at 20-23 weeks; in the proximal tibia, at 22-27 weeks; and in the proximal fibula, at 23-31 weeks. A discrepancy in age between radiographic and histologic closure of the growth plate occurred in 3.6% of the femora, 10.9% of the tibias, and 16% of the fibulas.

Magnetic resonance imaging of pediatric disorders of the ankle and foot

This article discusses the unique contribution of MR imaging to the evaluation of selected pediatric disorders of the ankle and foot. MR imaging is helping to unravel the complex congenital malformation of talipes equinovarus. It is the study of choice for the examination of intraarticular abnormalities such as Trevor's disease. The MR imaging staging of osteochondritis dissecans and delineation of a tarsal coalition have shown great promise in guiding surgical management of these abnormalities.

Use of the orthofix limb alignment grid in the treatment of infantile tibia vara

The use of a dome osteotomy in the treatment of infantile tibia vara is reportedly associated with insufficient intraoperative assessment of the correction achieved. This article discusses a method to overcome this problem and the long-term advantages of using a dome osteotomy in the treatment of this disease.

Diagnosis of osteoid osteoma in the child

Fifty-two cases of osteoid osteoma in children under 5 years of age were collected from the English literature and reviewed, along with seven cases from the Hospital for Joint Diseases. Analytic emphasis was placed on the clinical and radiologic difficulties encountered in the diagnosis of osteoid osteoma in children. Diagnosis is especially challenging in patients that are just beginning to walk. Osteoid osteoma is often confused with many other entities. Although pain was the most frequent clinical manifestation, it was absent in 12% of cases; limp tenderness, swelling, and atrophy were the next most frequent findings. When standard radiographic findings proved negative for this condition, technetium bone scans were of considerable efficacy in identifying the tumor. When used, computerized tomograms permitted visualization and precise localization of the tumors in all cases. Bone deformities and leg-length discrepancies were found in more than 25% of the cases. Mini-block excision is recommended at diagnosis.

Osteoid osteoma under the age of five years. The difficulty of diagnosis

Ninety-one cases of histologically confirmed osteoid osteoma were collected during an 11-year period; of them, seven (7.6%) had onset of symptoms while younger than five years of age. Special diagnostic difficulties were found in this specific age group: most cases were misdiagnosed or diagnosed incorrectly. The time between the onset of symptoms and the diagnosis varied from three months to five years. Although pain was present in six patients, in four cases, other concomitant signs and symptoms attracted more attention and led to a misdiagnosis and unnecessary invasive procedures. Gait disturbance (limp) was the second most frequent sign and was always present when the lower extremity was affected. In five cases, initial radiographs were not conclusive. Bone scans were very sensitive and conclusive in three cases where radiographs were atypical. Computerized tomograms always located the tumor.

Tarsal navicular position after complete soft-tissue clubfoot release

The navicular position was evaluated (according to Simons' criteria) on anteroposterior and lateral roentgenograms of 45 clubfeet that were treated with complete soft-tissue release without internal fixation. The evaluation was performed an average of 28 months after surgery. Position of the navicular correlates well with the functional rating score system. Navicular position can be viewed as an indicator for clubfoot correction. Internal fixation of the talonavicular joint was correlated with favorable correction of deformity.

Complete soft-tissue clubfoot release with and without internal fixation

Two groups of patients who underwent soft-tissue release of clubfoot are compared. In group I, internal fixation (two Kirschner wires) was used for 6 weeks to retain correction of clubfoot. In group II, no internal fixation was used. Patients from the two groups were operated on by one surgeon using the same procedure. Because there was no statistically significant difference in functional result between the two treatment groups (P = .08; Mann-Whitney Test), the authors recommend avoiding internal fixation (with all the associated problems) in cases of uncomplicated clubfoot, and encourage early removal of the cast and frequent manipulations to prevent stiffness of the joints and reduce the recurrence rate.

Avascular necrosis of the femoral head as sequela of fracture of the greater trochanter. A case report and review of the literature

After a fall from a tree, a 12-year-old boy sustained a fracture of the greater trochanter and was subsequently treated by open reduction. Twenty months after surgery, the hip developed to a flexion contracture, limb-length discrepancy, a collapsed, irregular-shaped femoral head with sclerotic areas, and a metaphyseal cyst. A growing child with avascular necrosis of the femoral head after fracture of the greater trochanter seems not to have been reported in the English language literature.

Pavlik harness versus Frejka splint in treatment of developmental dysplasia of the hip: bicenter study

A bicenter study was conducted to compare the results of treatment in developmental dysplasia of the hip (DDH) with Frejka splint versus Pavlik harness. Eighty-four dislocated hips were treated by the Frejka splint, and 48 dislocated hips were treated by the Pavlik harness. Failure of reduction was 10% with the Frejka splint and 12% with the Pavlik harness. Avascular necrosis (AVN, mostly type 1) was detected in 7% of Frejka patients versus 6% in Pavlik patients. The Frejka splint is simpler to use and if properly applied may be as safe as the Pavlik harness for DDH treatment.

Use of tissue expansion in clubfoot surgery

Tissue expansion was used successfully to prepare adequate soft tissue for closure following a difficult clubfoot correction. The gradual expansion was done weekly at the outpatient clinics (average 3-4 months). The procedure proved to be useful in severe cases of clubfoot.

Excision of the posterior tibial tendon during clubfoot release

In 50 patients (72 clubfeet), the posterior tibial tendon was excised during complete soft tissue clubfoot release. The end results after an average of 3 years were graded as follows: 55.5% excellent, 29.3% good, 8.3% fair, and 6.9% poor. Heel varus and forefoot adduction were the main causes for recurrence. Heel valgus occurred in one foot. Excision of the posterior tibial tendon is safe, does not lead to overcorrection, and may prevent further scarring created when the tendon is lengthened.

Postpoliomyelitis syndrome problems of knee function: a review

Postpoliomyelitis syndrome describes a ¿new¿ weakness, unrelated to any other neurological or medical disorder. It appears 10 to 15 years or more after recovery from the initial paralysis. This new weakness interferes with activities of daily living. The management of postpoliomyelitis syndrome may include orthotics, special exercises, a change in their lifestyle, or a combination of these regimens. This article is especially concerned with knee joint stabilization in various deformities that are weakened by the postpoliomyelitis syndrome.

Tips of the trade. Computerized tomography--guided excision of osteoid osteoma

Excision of osteoid osteoma nidus utilizing a Kirschner wire for preoperative marking of the lesion and a CORB biopsy set for excision is described. The procedure is performed in a computed tomographic scan unit under local anesthesia and results in minimal postoperative discomfort.

Osgood-Schlatter lesion: fracture or tendinitis? Scintigraphic, CT, and MR imaging features

To determine whether the Osgood-Schlatter lesion (OS) is produced by avulsion fracture or injury to the patellar tendon, all images obtained in 28 cases of OS in 20 patients (16 scintigrams, 34 computed tomographic [CT] scans, and 27 magnetic resonance [MR] images) were retrospectively analyzed. In 21 cases, imaging was performed before and after treatment; in 20 cases, relief from pain was complete at the time of repeat examination. In all patients (100%), abnormal size of the tendon, decreased attenuation, and increase in signal intensity were compatible with the CT and MR imaging appearance of tendinitis. Distended deep infrapatellar bursa was a frequent finding, particularly on MR studies. These abnormalities had partially disappeared at follow-up examination. An ossicle was seen in only nine of 28 cases (32%); in three of seven cases with follow-up, the ossicle remained nonunited to the tibial tuberosity on follow-up studies despite relief from symptoms. This implies that healing of fracture is not essential for relief from symptoms. These results strengthen the argument that in most cases of OS, insult to the tendon and associated soft tissues, rather than avulsion fracture, causes OS.

Pelvic osteotomies in children

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New method of limb deformities correction in children

A new "bloodless" technique (Ilizarov) was used to correct 36 limb deformities in 29 children. There were six leg length discrepancies, five achondroplasias, four deformed feet, five joint contractures, one rotational deformity of tibia, and in three the apparatus was used as an external fixator after corrective osteotomy. Lengthening was accomplished in 15 of the 16 procedures (93%). Average increase in femur length was 10 cm (32%), in tibial length 7.5 cm (30%), in humerus 11 cm (40%). Bony union was achieved in two out of five pseudoarthroses. Four deformed feet were fully corrected. Joint contractures were corrected in four out of five. The complication rate is as high as in other methods but with the Ilizarov apparatus, longer segments of bone were lengthened and more complex deformities were treated. Complications lessened as experience was gained.

Revision surgery in clubfeet

The reoperated clubfeet of 29 children aged one to 12 years were reviewed. The surgical procedure most often used in revision surgery was recomplete soft-tissue release alone or combined with plantar release, calcaneocuboid fusion, and capsulotomies of the navicular-first cuneiform-first metatarsal joint. In 27 of 29 feet, acceptable results were achieved. Nineteen were excellent and good results. An algorithm that suggests surgical solutions to a variety of clubfoot deformities in different age groups has been developed, as well as an objective rating system, to evaluate the long-term results of revision surgery of clubfeet.

Discitis in children

Discitis is usually a benign, self-limiting disease that is frequently misdiagnosed. The disease usually leads to spontaneous disc-space narrowing and end-plate irregularity, which require no treatment and rarely cause morbidity.